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Uvéite de Vogt Koyanagi Harada récidivante à la phase initiale et pachychoroïde inflammatoire persistante

Vogt-Koyanagi-Harada (VKH) disease is a bilateral, granulomatous panuveitis typically associated with serous retinal detachments (SRD). The VKH disease presents a roughly good long term out. However the visual prognosis could be threatened by multiple inflammatory recurrences. We discuss the interest of repeated retinal multi-imaging in recurrent VKH posterior uveitis.

Recurrent VKH posterior uveitis are reported in 3 cases : 18, 27, and 43 years old women with typical acute onset of VKH disease. A prompt clinical, biological and radiological work up ruled out others causes of SRD. High doses of corticosteroids were initiated with a quick good response on visual acuity and macular SRD. However, close follow up detected posterior recurrence with visual acuity (VA) drop while systemic corticosteroid were slowly tapered.

Repeated retinal multi-imaging showed a persistent pachychoroid in EDI OCT in 1 patient (case 2), a delayed choroidal filling in ICGA in 2 patients (cases 2 and 3), while in 1 patient (case 1) persistent peripheral choroidal nodular involvement was only seen in ICGA. Repeated high doses of corticosteroid associated with immunosuppressive drugs in 2 patients were delivered.  At one year, VA was completely restored in all eyes of the 3 patients with no further VKH uveitis recurrences.

In angiography, choroidal involvement had been showed including hypofluorescent round dots associated with early choroidal stromal vessel hyperfluorescence, resolving on high-dose immunosuppressive therapy ; Moreover we showed a delay in choroidal arterial filling that may induce choriocapillaris ischemic lesions and low drug doses delivered in choroidal stroma. Choroidal involvement was found persistent in the current cases even though an initial quick good response to the corticosteroids pulses were seen on VA and retinal thickness. Retinal blood-flow measured with laser speckle flowgraphy was found significantly lower in recurrent VKH group. This physiopathological statement could explain why the corticosteroid treatment seems to be inefficient for some patients : the reached prednisone concentration in choroidal stroma may be low in the thickened, folded inflammatory choroid. So while tapering an initial successful treatment of acute VKH, a choroidal imaging checking may be a useful tool in VKH uveitis management to prevent from long term visual function alterations.

Choroidal imaging using both EDI-OCT and ICGA may be a useful tool in VKH uveitis management to prevent from visual function alterations.